Initial experience in laparoscopic partial nephrectomy for renal tumor with clamping of renal vessels.

摘要

PURPOSE: To describe our initial experience with laparoscopic partial nephrectomy (LPN) with clamping of the renal vessels before tumor excision and suturing of the renal parenchyma. PATIENTS AND METHODS: Between July 2001 and April 2002, 19 consecutive patients underwent transperitoneal LPN in our institution, 14 for tumors <4 cm with suspicion of renal-cell cancer and 5 for suspicion of angiomyolipoma at CT with one tumor confirmed histopathologically by percutaneous needle biopsy. We divided these patients into the first 10 cases (Group 1) and the last 9 cases (Group 2). One patient had end-stage renal disease but was not on dialysis; the remaining patients had elective partial nephrectomy. Initially, a ureteral catheter was placed. The partial nephrectomy was performed with clamping of the renal vessels, so that the tumor was excised with cold scissors. Intracorporeal cooling of the kidney was achieved by a ureteral catheter connected to a 4 degrees C solution flowing to the renal pelvis during thewhole procedure until the clamps were released. Intracorporeal free-hand suturing was exclusively used to close the collecting system (when opened) and to approximate the renal parenchyma. RESULTS: All procedures were completed laparoscopically. The mean renal warm ischemia time was 28.5+/-7 minutes (range 15-47 minutes). The mean laparoscopic operating time was 125+/-37 minutes (range 90-390 minutes). The mean intraoperative blood loss was 290+/-276 mL (range 25-1200 mL). Two patients required blood transfusion, and four had complications. There was immediate deterioration in renal function (creatinine 1.42+/-0.56 mg/dL), but improvement was seen at 1 month (1.17+/-0.34 mg/dL). There were no statistically significant differences in operative features and outcomes in Groups 1 and 2, but there were improvements in the mean operating time by 30 minutes, the mean intraoperative blood loss by 113 mL without any transfusion, and the mean renal warm ischemia time by 6 minutes. There was only one patient in Group 2 with a complication. The surgical margin was negative for tumor for all patients. Postoperative pathology examination showed renal-cell cancer in 11 patients (pT1), oncocytoma in 3 patients, and angiomyolipoma in 5 patients. The mean tumor grade was 2. The mean tumor size was 25.8+/-11.6 mm with a mean tumor-free margin of 2.6+/-2.4 mm. The median follow-up is 3 months, so oncologic outcome cannot be assessed. CONCLUSION: The technique of LPN can be standardized and should be proposed for small tumors when they are not invading the hilum. Clamping the renal pedicle allows better vision for more accurate tumor excision with a safety margin and hemostatic suturing of the parenchymal defect, resulting in less blood loss and shorter operative time, parameters that improve with experience.